Description:
Utilize InterQual, MCG, NCD, and LCD criteria to review inpatient and outpatient cases.
Assess patient documentation to determine the appropriateness and necessity of recommended services.
Work alongside medical directors and interdisciplinary teams to address complex clinical scenarios.
Ensure all reviews meet payer, regulatory, and internal compliance standards.
Maintain accurate, organized, and complete documentation for all case evaluations.
Support internal quality checks, audits, and process improvement initiatives